In the report, Ukom describes challenges that the health and care services may face when conducting incident investigations after serious adverse events. The report emphasises the importance of adopting a systems perspective to promote learning and improvement. The findings are based on reviews of the services’ incident analyses, interviews, dialogue with the services, and input from professional communities.
The report shows that when health and care services struggle to adopt a systems perspective in investigations of serious events, explanations may be limited to individuals and causes closely linked to the event itself. This can result in proposed measures having little impact on underlying factors that contributed to the serious adverse event.
By applying a systems perspective, organisations are better equipped to identify connections and implement measures that support learning and improvement, thereby contributing to better patient safety.
To ensure a systems perspective in incident investigations, a shared understanding of what this concept entails and its significance for the review is needed. Everyone requires basic competence, but those leading investigations need deeper knowledge. Good methodological tools can strengthen the work, but understanding what a systems perspective is becomes important before using them.
The report provides two recommendations:
- Update and further develop the tool “Risk and Incident Analysis – Handbook for Health Services” with a systems framework and other relevant tools.
- Strengthen competence both in understanding what a systems perspective involves and in applying it in system-based investigations.
The translation from Norwegian to English is based on AI. Ukom has reviewed, edited and quality assured the translation.